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Judeul

Localitatea
Spitalul
Secia

Nr. nregistrare SC

..................

CNP pacient

.....................................................

............................................................

ntocmit de: ...............................................................


parafa medicului

................................................................

FOAIE DE OBSERVAIE CLINIC GENERAL


NUMELE .........................................
Data naterii: zi

lun

Domiciliul legal: judeul

an
Localitatea

.............................................................. Sect.

internrii:

PRENUMELE ........................................................

Sexul M/F

Grup sangvin: A/B/AB/0; Rh + / ..........................................................

Mediul U/R

Alergic la:

Str. ....................................................................... Nr. ......

Data

ora

Reedina: judeul

Localitatea

Sect.

Str. ....................................................................... Nr. ......

Mediul U/R

Cetenie:

Romn

.........................................................................

Strin

zi

lun

an

Data externrii:

ora

zi

an

....

Greutatea la natere (nou nscui)

grame

lun

Ocupaia: fr ocupaie (1); salariat (2); lucrtor pe cont propriu (3);


patron (4); agricultor (5); elev/ student (6); omer (7); pensionar (8)

Nr. zile spitalizare

Locul de munc ..............................................................................

Nr. zile c.m. la externare

.........................................
.........................

Nivel de instruire: fr studii (1); ciclu primar (2); ciclu gimnazial (3); coal profesional (4); liceu (5)
coal postliceal (6); studii superioare de scurt durat (7); studii superioare (8); nespecificat (9)
C.I / B.I. seria

Nr.

Statut asigurat:

Certificat natere (copil) seria

Nr.

Asigurare voluntar

Neasigurat

Categ. asig. CNAS: salariat (1); coasig. (2); pensionar (3); copil<18 ani (4); elev/ucenic/student 18-26 ani (5);
gravid (6) veteran (7); revoluionar (8); handicap (9); PNS (10); ajutor social (11); omaj (12); alte (13)
Tipul internrii: urgen (1); trimit. MF (2); trimit. ambulatoriu (3); transfer interspit. (4); la cerere (5); alte (9)
Criteriu internare: urgen (1); diagnostic (2); tratament (3); nedeplasabil (4) epidemiologic (5); medic ef (6)
Diagnosticul de trimitere: .................................................................................................................................

................................ .......................................... ................................ ................................ ...........................


Diagnosticul la internare: .................................................................................................................................

................................ ................................ ....................... ........ ..............................................


Semntura i parafa medicului
................................................

Diagnosticul la 72 de ore:

.............................. ................................ ................................ ................................ ................................ ..............................

.................................................................................................................................................................................................................................................................

Diagnosticul principal la externare:................................

................................ ..................... ...............................................

................................ ................................ ........................................ ................................ ................................ ...........................................

Diagnostice secundare la externare (complicaii / comorbiditi):


1. ................................ ................................ ........................................ ................................ ................................ ...........................................
2. ................................ ................................ ........................................ ................................ ................................ ...........................................
3. ................................ ................................ ........................................ ................................ ................................ ...........................................
4. ................................ ................................ ........................................ ................................ ................................ ...........................................
5. ................................ ................................ ........................................ ................................ ................................ ...........................................
6. ................................ ................................ ........................................ ................................ ................................ ...........................................
Semntura i parafa medicului ef
...............................................

Semntura i parafa medicului curant


.......................................................

23.3 A4 t2

Asigurat CNAS
Asig. oblig. CAS

Asig. facultativ CAS

Eurocard

Acorduri internaionale

Intervenia chirurgical principal:

.....................................................................................................................................................................

..................................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................

Consimmntul pentru intervenie: ...........................................................................................................................................................................


medic operator principal ............................................................................................................................................
Echipa operatorie:

medic operator II

...........................................................

medic ATI

medic operator III


Data interveniei chirurgicale: zi

..........................................................

asistent/

luna

..........................................................
..............................................................

an

Intervenii chirurgicale concomitente (cu cea principal):


1........................................................................................................................................
medic operator principal
Echipa operatorie:

............................................................................................................................................

medic operator II

...........................................................

medic ATI

medic operator III

..........................................................

asistent/

..........................................................
..............................................................

2........................................................................................................................................
medic operator principal
Echipa operatorie:

............................................................................................................................................

medic operator II

...........................................................

medic ATI

medic operator III

..........................................................

asistent/

..........................................................
..............................................................

Alte intervenii chirurgicale:


1........................................................................................................................................
medic operator principal
Echipa operatorie:

............................................................................................................................................

medic operator II

...........................................................

medic ATI

medic operator III

..........................................................

asistent/

..........................................................
..............................................................

Data interveniei chirurgicale: zi


luna
an
2........................................................................................................................................
medic operator principal
Echipa operatorie:

............................................................................................................................................

medic operator II

...........................................................

medic ATI

medic operator III


Data interveniei chirurgicale: zi

..........................................................

asistent/

Examen citologic

luna

..........................................................
..............................................................

an

..................................................................................................... ................................................................................................................

Examen extemporaneu

..................................................................................................... ...................................................................................................

Examen histopatologic (biopsie pies operatorie)

.....................................................................................................

...................................

Transfer ntre seciile spitalului:


Secia

Diagnostic

Data intrrii (ora) Data ieirii (ora)

Starea la externare: vindecat (1); ameliorat (2); staionar (3); agravat (4); decedat (5)
Tipul externrii: externat (1); externat la cerere (2); transfer interspitalicesc (3); decedat (4)
Deces: intraoperator (1); postoperator: 0 23 ore (2); 24 47 ore (3); > 48 ore (4)
Data i ora decesului:

zi

luna

an

ora

Nr. zile
spitalizare

Diagnostic
a.
b.
I
c.
d.
II

n caz de deces:
Cauza direct (imediat) .............................................................. .............................................................. ..........................................
Cauza antecedent .............................................................. .............................................................. .........................................................
Stri morbide iniiale:
.............................................................. .............................................................. .......................................................................................................
.............................................................. .............................................................. .......................................................................................................

Alte stri morbide importante .............................................................. .............................................................. ........................................


.............................................................. ..................................................................................................................... .........................................................

Diagnostic anatomo-patologic (autopsie), macroscopic:

...........................................................................................................................

.............................................................. ..................................................................................................................... .............................................................................


.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................

Microscopic:

.............................................................. ..................................................................................................................... ...........................................

.............................................................. ..................................................................................................................... .............................................................................


.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................

Codul morfologic (n caz de cancer)

Explorri funcionale:
Denumirea
1.

.............................................................. ....................................................................................................

2.

.............................................................. ....................................................................................................

3.

.............................................................. ....................................................................................................

4.

.............................................................. ....................................................................................................

5.

.............................................................. ....................................................................................................

6.

.............................................................. ....................................................................................................

Codul

Nr.

Codul

Nr.

Codul

Nr.

Investigaii radiologice:
Denumirea
7.

.............................................................. ....................................................................................................

8.

............................................................. ....................................................................................................

9.

............................................................. ....................................................................................................

10.

............................................................. ....................................................................................................

11.

............................................................. ....................................................................................................

12.

............................................................. ....................................................................................................

Alte proceduri terapeutice:


Denumirea
13.

............................................................. ....................................................................................................

14.

............................................................. ....................................................................................................

15.

............................................................. ....................................................................................................

16.

............................................................. ....................................................................................................

17.

............................................................. ....................................................................................................

18.

............................................................. ....................................................................................................

ALTE OBSERVAII:
1

MOTIVELE INTERNRII:

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

.............................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

ANAMNEZA:

...........................................................................................................................................................................................................................

a) Antecedente heredo-colaterale

..........................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

b) Antecedente personale, fiziologice i patologice

................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

c) Condiii de via i munc

.....................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

d) Comportamente (fumat, alcool etc.)


.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

e) Medicaie de fond administrat naintea internrii (inclusiv preparate hormonale i imunosupresoare


.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

ISTORICUL BOLII:

..............................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
.............................................................................................................................................................................................................................................................

EXAMENUL CLINIC GENERAL .............................................................................................................................................................................


EXAMEN OBIECTIV .........................................................................................................................................................................................................

Starea general ...................................................................................................... Talie ....................................... Greutate ...............................


Starea de nutriie .................................................................................. Starea de contien ............................................................................
Facies ...........................................................................................................................................................................................................................................
..
Tegumente
.................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................
.

Mucoase

....................................................................................................................................................................................................................................

..
.............................................................................................................................................................................................................................................................

Fanere ..........................................................................................................................................................................................................................................
..

esut

conjunctiv-adipos

..................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
..

Sistem

ganglionar

................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.

Sistem

muscular

....................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

Sistem

osteo-articular

.......................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
..
...........................................................................................................................................................................................................................................................
..

APARAT RESPIRATOR ...................................................................................................................................................................................................


.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

APARAT CARDIOVASCULAR ..................................................................................................................................................................................


............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.

APARAT DIGESTIV ...................................................................................................................................................................................................


............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
.............................................................................................................................................................................................................................................................

FICAT,CI BILIARE, SPLINA ...................................................................................................................................................................................


..........................................................................................................................................................................................................................................................
.
..........................................................................................................................................................................................................................................................
.
..........................................................................................................................................................................................................................................................
.

APARAT URO-GENITAL ...............................................................................................................................................................................................


............................................................................................................................................................................................................................................................
.

SISTEM NERVOS, ENDOCRIN, ORGANE DE SIM

.................................................................................................................................

............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
.............................................................................................................................................................................................................................................................

EXAMEN ONCOLOGIC: .................................................................................................................................................................................................


1. Cavitatea bucal ............................................................................... ............................................................................... ...............................................
2. Tegumente

............................................................................... ............................................................................................ ..............................................

3. Grupe ganglioni palpabile


4. Sn

............................................................................... ............................................................................... ........................

............................................................................... ............................................................................................................. ...............................................

5. Organe genitale feminine

............................................................................... ............................................................................... .........................

6. Citologia secreiei vaginale ............................................................................... ............................................................................... .........................


7. Prostat i Rect ....................................................................................................... ............................................................................... .........................
8. Alte

............................................................................... .................................................................................................................................. .........................

................................................................................................. ............................................................................... ...........................................................


................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

ALTE EXAMENE DE SPECIALITATE

..................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................


................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

EXAMENE DE LABORATOR

......................................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................


................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

EXAMENE RADIOLOGICE (rezultate) .................................................................................................................................................................


................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

EXAMENE ECOGRAFICE (rezultate)

...................................................................................................................................................................

................................................................................................................. ............................................................................... ..........................................................


.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ...........................................................

INTERVENII CHIRURGICALE (numrul interveniei chirurgicale, protocol operator):


................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

EXAMENE ANATOMO-PATOLOGICE:

.............................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................


................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ..........................................................


.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ..........................................................
.
................................................................................................................. ............................................................................... ...........................................................

SUSINEREA DIAGNOSTICULUI I TRATAMENTULUI:


CLINIC: ..................................................................................... ............................................................................... ..................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

PARACLINIC: ....................................................................... ............................................................................... ...................................................


.................................................. ............................................................................. ............................................................................... ............................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

EPICRIZA:

...................................................................................... ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................


................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
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................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

Semntura i parafa medicului,


......................................................

FOAIE DE TEMPERATUR ADULI


CNP

Numele . Prenumele ....


Anul luna Nr. foii de observaie Nr. salon .. Nr. pat ..

Temp

Puls

T.A.

Resp.

Ziua
Zile de boal
D S

D S

D S

D S

D S D S

D S

D S

D S D S

D S

35

30

160

41

30

25

140

40

25

20

120

39

20

15

100

38

15

10

80

37

10

60

36

Lichide ingerate
Diurez
Scaune
Diet

D S

D S

D S D S

D S

D S

D S D S D S

D S

D S

D S

D S

D S D S D S

FOAIE DE EVOLUIE I TRATAMENT


DATA

EVOLUIE

10

TRATAMENT